Biomedical subjects
Publications and source records attributed to Trevor A Kletz.
Whenever we hear of an accident elsewhere we are eager to learn what happened and what recommendations have been made to prevent it happening again. However, we can learn as much from past accidents that have been forgotten or were never widely reported. Some such accidents are described, including entry to confined spaces, the collapse of a gasholder and the collapse of a tank for an unusual reason.
Finding the causes of an accident or operating problem and deciding what actions to take to prevent it happening again is rather like dismantling a set of Russian dolls (Fig. 1). Each time we ask "why?" (or a similar searching question) we find another cause besides the ones we have found already and another action (or set of actions) we can take to prevent similar accidents occurring again. Many investigators stop too soon. This occurred at Flixborough, at Bhopal and in the investigation of many lesser-known accidents. We are more likely to find the deeper causes and the more original actions if groups of people with wide interests and experience are able to take part in the investigations or discuss the investigation reports. We should never look at an accident report as "closing out" a problem. As we read it, we should ask ourselves, "what else could be done?"
Some process accidents and the actions needed to prevent them occurring again are described. They illustrate the following points: Some investigators are too eager to recommend changes in instructions or better observation of them than to look for ways of removing hazards or for changes in design that will make an accident less likely. Some people fail to calculate the effects of changes or the time required for them to take place. Facts that are well known in one industry or company may be unknown in another. The incidents have been chosen because of their value as learning experiences.